❤️👋 hi Sigal!

My prior and current institution very rarely use it, so wondering what colleagues’ experiences with it are.

I’ve used for a tx pt w/ simultaneous disseminated Nocardia & CRE Pneumonia & was like “oh! that’s what it’s for!” 🤣

I’ve thought of some scenarios:

- MDR PsA R to CAZ-AVI & TOL-TAZ

- Polymicrobial infx w/ MDR PsA and CRE, especially if requiring anaerobic & some E faecalis coverage?

Others?

I was not aware of NSV mechanisms until attending a lecture on the subject by Jonathan Li, who is a reservoir expert.

I’ve referred a couple of pts to his lab, but access to ultra-sensitive viral characterization is difficult outside major academic research centers.

www.nature.com/articles/s41...

Thank you for the articles, Sébastian! Very interesting patients!

I feel like we need to increase awareness of this phenomenon amongst clinicians - because it’s actually not THAT uncommon, & it causes a lot of “fire drills” w/ changes in ART, multiple repeat tests & distrust… (1/2)

I love you @sanfordguide.bsky.social !

You help me do me job better every day! ❤️😍

Hopeful I can just abandon X soon and not have to cross post!

What other common scenarios come up in your practice? Feel free to add, correct & comment!

And finally, the amazing ART chart created by @serotavirus.bsky.social

drive.google.com/file/d/1Bfsq...

Useful resources for ART Management:

- Stanford Drug Resistance Database - hivdb.stanford.edu

- HIVassist.com

- IAS-USA - www.iasusa.org/wp-content/u...

- Liverpool HIV Drug Interactions Checker - www.hiv-druginteractions.org/checker

- Crushing & liquid ART: www.hivclinic.ca/main/drugs_e...

It ain't "broke," but you may as well "fix" it!

More about ART Switch, two-drug regimens, switching in VF, and other scenarios in our review article:

www.sciencedirect.com/science/arti...

And remember to also always incorporate:

- pt's preferences
- pill burden & size
- food requirements
- IM vs PO medication
- tolerability
- pregnancy
- toxicities
- DDIs
- caution if switching from a higher to a lower barrier to resistance regimen!

12) Efavirenz

Not very lipid friendly, has risk of DILI besides its well-established neuropsychiatric effects.

I have a low threshold to switch, especially if depression.

Watch for weight gain in people switching off EFV + TDF !

11) Abacavir

People on DTG/ABC/3TC come up once in a while. Long term use of ABC is associated with increased cardiovascular risk.

Would discuss switching with patient!

10) Older PIs

Numerous toxicities - switch!

The only PI we use in practice is darunavir - better tolerability & high barrier to resistance.

(Continuing atazanavir in pts who really don't want to switch & don't have kidney/GB stones or distressing jaundice might be reasonable)

9) AZT

Legacy un-switched AZT comes up once in a while due to a historical practice of using AZT in salvage regimens for people w/ K65R.

Outside perinatal HIV, hard to imagine a role for AZT nowadays w/ its BM & mitochondrial toxicities. There's better options - Switch!

8) A word about rilpivirine...

TAF/FTC/RPV came out in 2016 and became popular due to its small pill size. It's well-tolerated & safe, but check & inform:

-Needs full meal
-Cannot be given w/ PPIs
-Relatively low barrier to resistance, & if it develops, cannot use IM CAB/RPV

7) Persistent low level viremia (pLLV)

ART is often "intensified" in pLLV (eg, adding PI)

If non-adherence & resistance excluded & especially if pLLV is unchanged post switch, it may be due to factors that are not modifiable by ART (eg, clonal expansion of reservoir proviruses)

6) INSTI drug interactions

INSTIs are amazing, but there's a few DDIs. DTG increases metformin levels. Several anti-epileptics decrease INSTI levels!

The issue of pts on IM CAB (or PO INSTIs) who get phenobarbital for EtOH withdrawal sometimes comes up as well!